*1.Contact Info(Required.)

Name

Phone

E-Mail

Gender

Age

State

*2.Patient safety monitoring is important to our client. We are required to pass on details of adverse events or other safety information that may be mentioned during this market research to the pharmaceutical company sponsoring the study. Although what you say will be treated in confidence, if you mention safety information during the study, we are obligated to report it to the sponsor company’s drug safety department even if you have already reported it to the company or regulatory authorities. All information forwarded to our client’s Drug Safety department is treated in accordance with local privacy laws.(Required.)

Yes

No

*3.If you mention any adverse events or other reportable safety information, you have the choice whether to waive the anonymity given to you under the Market Research Codes of Conduct specifically in relation to the reportable safety information you mention. If you are willing to waive your anonymity, your name and contact information could be provided to the research Sponsor and you could be contacted for follow-up questions specifically regarding the safety information. If you do not want to waive your anonymity, you can still participate in this research and the safety information will be reported anonymously. Regardless, everything else you say during the study will continue to remain anonymous.

Do you prefer to preserve the confidentiality of your information and have it reported anonymously or do you consent to having your contact information provided to the research sponsor for possible follow up?(Required.)

1. Preserve confidentiality of your information (Do not waive confidentiality)

2. Consent to having your personal information shared with the project sponsor (Waive confidentiality)

*4.Do you, or anyone in your household, work in any of the following types of industries / companies?(Required.)

For a marketing or market research department, agency or consulting firm

Local, state or federal government

Healthcare (including doctors, nurse, hospital/office staff, pharmacy etc.)

Online health or medical service provider

Healthcare non-profit/advocacy group

A company involved with the manufacturing, distribution or sales of prescription or over-the-counter medications, or medical devices

Federal Drug Administration (FDA) or a government or health regulatory agency

None of these

*5.Have you ever been clinically diagnosed by a healthcare provider with any of the following conditions? Please select all that apply.(Required.)

Anxiety

Bipolar Disorder

Depression

Dissociative Identity Disorder

Eating Disorder

Post-Traumatic Stress Disorder (PTSD)

Schizophrenia

None of the above